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New advances that enable identification of glioblastoma recurrence

Nature Reviews Clinical Oncology volume 6, pages 648–657 (2009)Cite this article

Abstract

Postoperative adjuvant radiation therapy and temozolomide chemotherapy have become the standard care for newly diagnosed malignant gliomas. The efficacy of these therapies has led to an increase in pseudoprogression and radiation necrosis, both of which are treatment-related effects whose appearance on standard MRI with gadolinium-based contrast agents resembles that of tumor progression or recurrence. Accurate diagnosis of these post-treatment lesions as either tumor recurrence or treatment effects (pseudoprogression or radiation necrosis) is important to determine the patient's prognosis. Modern advancements with magnetic resonance spectroscopy (MRS), diffusion-weighted imaging (DWI), and PET scans have shown promise for distinguishing tumor recurrence from treatment effects. Advances in radiographic techniques will become critically important with the emergence of new antiangiogenic therapies. Consequently, MRS, DWI, and PET need to be incorporated into routine post-treatment investigations to improve the specificity and sensitivity of distinguishing tumor recurrence from treatment effects. Further research will also be needed to develop improved algorithms that use these modalities, and to develop new modalities with even greater accuracy than those currently available.

Key Points

  • Temozolomide chemotherapy and radiotherapy have become the standard care for patients with malignant glioma

  • This therapeutic regimen has been associated with an increase in early, post-treatment, enhancing lesions on gadolinium-contrast MRI

  • These lesions are treatment effects, defined as either pseudoprogression (early radiographic changes) or radiation necrosis (later, subacute radiographic changes)

  • Pseudoprogression and radiation necrosis usually resolve spontaneously, although mass effects from radiation necrosis sometimes require surgical treatment; however, these changes are challenging to distinguish from tumor recurrence

  • Modern biologic and radiographic imaging techniques such as MRI, diffusion-weighted imaging, and magnetic resonance spectroscopy have shown potential in differentiating between tumor recurrence and radiation effects

  • Advances in radiographic and other imaging techniques used to detect tumors are needed; new antivascular therapies render standard contrast-enhanced MRI unreliable for assessing tumor recurrence

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Figure 1: The effects of radiotherapy as postsurgical treatment of glioblastoma.
Figure 2: Sequence of events in radiation necrosis.
Figure 3: Histopathologic features of radiation necrosis.
Figure 4: Conventional T1 gadolinium-enhanced MRI appearance of radiation necrosis.
Figure 5: Appearance of bevacizumab-treated glioma on conventional MRI.
Figure 6: MRS images of glioma after radiotherapy.

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Acknowledgements

We appreciate the editorial assistance with this manuscript provided by N. Huh. I. Yang, the first author, was partially supported by a University of California, San Francisco Clinical and Translational Scientist Training Research Award.

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    Isaac Yang & Manish K. Aghi

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Yang, I., Aghi, M. New advances that enable identification of glioblastoma recurrence. Nat Rev Clin Oncol 6, 648–657 (2009). https://doi.org/10.1038/nrclinonc.2009.150

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